I wish I was able to
interview Coach Saban but Tim Teebow and Marty Smith (ESPN) were lucky enough
to do so on an ESPN broadcast today “on the lake with Saban”. They asked
Coach Saban the same questions I would have. We are constantly struggling in
surgery to identify key leadership aspects to mold our uprising surgical
leaders and once again another great football coach has stated it so well, I felt
the need to pass this along. (Go to http://broadband.espn.go.com/video/clip?id=17383517)

MS- coach what are your
favorite memories here?

NS- the kids growing
up. One thing about it is when you move around a lot...family memories are
really important to your children. .... I tell everybody, we are always so
worried about getting ahead, the games your gonna win and all that.. but when
you get to my age at this station and you look back and say I wish I spent a
little bit more time doing that. ...you can't relive it. ....As you get older
some times you realize that some things are more important than when you are
coming up and you are trying to make it and you didn't value the memories as
much as you do now... And for everybody out there you gotta enjoy the moment.

MS-how far away from football will you let
yourself go (at the lake house)

NS- I don't feel like I
get away from football when I am out here.... I don't really get away from it
completely, like it doesn't exist, I know that maybe for a couple of hours
maybe I can go back to it, but the rest of the time my mind is completely clear
of it. The level of relaxation is so important to me and if I didn't do that I
could not have coached as long as I had.

TT- when in your career did you learn to
compartmentalize and put football in its place and family and the rest of your
life in its place.

NS- The last couple of
years when I was at Michigan state I had a philosophical change in my approach.
Up to that point it was all about winning...like I had to win, like I had to
prove myself all the time... And sometimes I feel like I affected the team and
made them feel that way. Where when I went to LSU I adopted the philosophy that
hey we are going to play one play at a time ... It was more fun for me, it was
more fun for the players..and we got a lot better results.

{This reminded me of a conversation I had after the Duke Faegin
leadership conference in May 2016, With Dr Sottile where he explained to me
that work life balance is not possible and you must find that happy medium
where you can accomplish what you need to regarding your work and then let it
go because you cannot be engaged simultaneously with your family and work or
both will suffer.

NS-complacency, being satisfied with where
you are. Complacency creates a complete disregard for doing what's right. You
can't just do what you feel like doin you gotta chose to do what helps you
accomplish the goals that you have and when you get complacent you lose respect
for winning. ..... I don't spend much time on the past, I really spend all my
time thinking about the next challenge.

MS - how important is
it to you to be a compass for these young men...as a man, much less as a
football player?

NS- my number one goal
for our players...is that they can be more successful in life because they were
involved in the program. And when they commit I tell them I don't want them to
commit to Alabama, I want them to commit to all the things we do to be
successful.

MS- what do you expect when you get back

NS leadership comes
from the power of one, you affect one person by the example you set, being
somebody they can emulate, caring about somebody, and tomorrow you affect two
more guys...and then next thing you know everybody is affecting everybody in a
positive way.

TT. How much harder is it to get to the top of
the mountain verses staying at the top of the mountain?

NS it's a whole
different set of challenges. In terms of getting people to buy in to doing the
things they need to do to accomplish the goals that they have and not be
satisfied with the goal they just accomplished. You gotta recalibrate every
bodies thinking.

On a side note, shortly after this broadcast ESPN held another Interview
with Coach Saban by correspondent Rece Davis later that afternoon.

RD (regarding
quarterback leadership) how much of that is innate and how much can be taught?

NS sometimes people
think leadership is that you stand up in front of a room and you influence a
hundred people with the speech that you give, or the enthusiasm that you
approach it with but really there is a power of one to me. Taking the time

Influencing a person here and a person there. And next thing you
know that spreads throughout your organization and people are buying into the
right things and next thing you know that works well from a team perspective.

I am indebted to Dean Taylor, MD for
inviting me to the Feagin Leadership Program Annual meeting at Duke University.
The topic on RESILENCY was one that I often pondered but was seldom able to
locate real experts to learn from. After our surprise visit from Coach Mike Krzyzewski, Wayne Sotile, PhD, discussed the role of building resistance
to BURNOUT as a key process when developing a resilient leader.

The first shocker came when Dr. Sotile
explained that the development of a ‘balanced’ life is a MYTH. All we ever hear
is how we need to balance our lives. He stated that inevitably what occurs when
one tries to balance out work, family, themselves and an intimate relationship,
is that you and those around you end up feeling angry, guilty or anxious, which
is certainly not the model of a “balanced” life. Unfortunately, surgical
professionals are at the top of the “most likely to be burnt out” list, so it
behooves us to understand and take charge of this process. So why are medical
professionals and especially surgeons so prone to burnout? As expected we are
all high producers used to high demands. When we have high control we do great,
but when we begin to lose control, then the stress levels go up. What happens
when we are stressed? We get temperamental, angry, distressed and develop
reduced mental processing powers: we
“get mean and stupid”. What happens when we become mean, stupid and
narcissistic? Those around us hate us and then we fight each other.

So who suffers when physicians hit the
burnout threshold? Well asides from us and our families, it turns out that our
patients and teammates suffer. There have been multiple studies that correlate
signs and symptoms of burnout to reduced quality of care due to an increase in
medical errors, increase in litigations, and decrease in patient compliance and
satisfaction.

How do we know if we are burnt out? Dr. Sotile
said that is easy, just look into the eyes of the ones we love, our teammates
and our patients. If you see a look of distrust, then rest assured you are
burnt out. If you are feeling guilty over or stressed over or arguing over
priorities in your daily life…. You are burnt out.

Is there anything we can do about this? The
obvious choice is to blame and correct the system: increase efficiency and
support, reduce documentation burden, develop leaders who foster engagement,
work on our community,…. And on and on…. Dr. Sotile said that ultimately, you
need to look into yourself and find what you personally can do for any real
change to occur. Sure, you cannot control 90% of the stuff going on around you
but if you really want to make a stance, figure out what 10% you can change. To
make any changes you need to: “use realistic roadmaps. Honestly assess
yourself. Counter hassles with uplifts, and deepen your relationships.”

At
the end of it all Dr. Sotile left us with these messages to take home:

“Face what is beneath your feet not what you are grasping for.”

“ You don't just decide to be resilient…You need health, You need
collaboration, you need career satisfaction, you need family satisfaction and
to have that you must be satisfied at work.”

“It's not the number of hours you work but your attitude when you
come home that affects your family- in the end you will see that, how you treat
someone at work affects how they
react when they get home.” So be nice to one another.

“Find Amusement, wonderment, pride, awe, and love as often as you
can”.

After
discussing this summary with Dr. Sotile, I had a few questions

·In
dealing w very busy, very focused, and very skeptical physicians- what's the
one thing you do that captures their attention to instill the desire to make a
change (assuming they were not deemed a disruptive physician and this was
recommended to them)?

·As
one takes on additional roles from being a clinician and family partner and
parent to include major leadership roles (Department Chair or Chief Surgery)
you essentially have gone from two to three "competing" interests all
of which are equally important. What's your advice to the leaders about making
sure everyone senses that you have not deprioritized them- that is you are not
even more distant?

·It's
easy to say "I don't sweat the small stuff" but in family, clinical
care and organizational leadership, what you class as the "small"
stuff likely is not small to your patients, family, or organization. So how
does one prioritize three seemingly non-intertwined worlds?

1.Q.
So in dealing w very busy, very focused, and very skeptical physicians- what's
the one thing you do that captures their attention to instill the desire to
make a change?A. Show how their lack of positive engagement (or
happiness) with work puts both their personal and family health and wellbeing
at risk.

2.Q.
As one takes on additional roles from being a clinician and family partner and
parent to include major leadership roles (department chair or chief surgery)
you essentially have gone from two to three "competing" interests all
of which are equally important. What's your advice to the leaders about making
sure everyone senses that you have not deprioritized them?A. Whether or not to accept that sort of
career-changing promotion is best treated as a family/marital decision.
Research has shown that burnout of Chairs, specifically, co-varies with
perception of marital support. (See the work of Steven Gabbe.) Secondly, key to
family satisfaction with the physician leader is the leader’s conveying that
whatever is important to each family member is just as important to him/her
(the Chair) as is the busy professional work he/she is engaged in…even if
he/she can’t be present as much as desired.

3.Q.
It's easy to say "I don't sweat the small stuff" but in family,
clinical care and organizational leadership, what you class as the
"small" stuff likely is not small to your patients, family, or
organization. So how does one prioritize three seemingly non-intertwined
worlds?

A.This is a particularly
difficult one. One key is managing one’s own
perfectionism; differentiating the arenas of life – and realizing that absolute
perfectionism (re: self-expectations and expectations of others) is not
adaptive, at minimum, in both organizational and family life. Also helpful is
adapting to the “infinite sloppiness” that is both the family developmental and
organizational developmental courses.

"With 14:38 to go in the second quarter of the 2015
AFC Championship Game against the Denver Broncos, Tom Brady tried to get the
ball to Rob Gronkowski, but was picked off by Denver linebacker Von Miller."
That's what the headlines said but I watched...

"With 14:38 to go in the
second quarter of the 2015 AFC Championship Game against the Denver Broncos,
Tom Brady tried to get the ball to Rob Gronkowski, but was picked off by Denver
linebacker Von Miller." That's what the headlines said but I watched that
play over and over I thought “wow, that was a great throw- if that was the
intended receiver”. It was as though Tom Brady did not recognize Von Miller was
even there. That triggered the question in my mind: hey coach, how do you train
star quarterbacks to maintain full situational awareness of their receivers and
defenders. In surgery we have to simultaneously keep situational awareness and
focus. Pilots practice load shedding where they eliminate distractions and
focus on specific gauges etc but separate the tasks out so that they are sure
one person is monitoring all the gauges. We try to do this in surgery but have
to keep aware of what is going on in the periphery without over distraction. So
my question is, how do you as a coach/quarterback train to keep awareness of
both your receivers and the defenders who are attempting to thwart your plans.
How do you focus on the tight ends and wide receivers but not forget the
defenders. I thought about this as I watch Tom Brady and a few others throw
right into the arms of wide open defenders during the playoffs.....I teach the
residents to not forget about the Gorilla-- from the Harvard Gorilla -
basketball studies from the 80s. Others warn me to not overwhelm trainees with
watching for everything or it will paralyze them. Now all I had to do was find
a coach to answer that question. I already asked Colt McCoy these questions and
he succinctly explained that they do this through a “lot of practice”, but I
hoped to delve into that deeper. He deferred this to his father, Coach Brad
McCoy who was gracious to take time to explain this to me. The conversation
however quickly turned to leadership development.
SITUATIONAL AWARENESS:
Our conversation started off on my original question of how does a Coach teach
a player to have simultaneous situational awareness, but be able to maintain
focus on their intended receiver? Pilots practice load shedding to avoid
distractions by inconsequential gauges but need to maintain situational
awareness at the same time- of course they do this by allocating attention to
one person specifically to assure that both the pilot and copilot are not
focused on the same problem, averting the attention from a more significant
one. Well, I got a great answer:
“In football we do a lot of presnap evaluation. You call the play and the
receivers know exactly where they are supposed to be. The quarterback assesses
the defense to see if they are going to be routed where he thinks they will be
and if something happens and you are uncertain, you call an audible”.
“It takes a lot of prep and identification of the defense structure before the
snap”
“It is all about teamwork and trust. It is a learned process. You practice till
you are sure your receiver is going to be in the exact window of opportunity he
is supposed to be in. He is supposed to be there at the exact time you expect
him there. That window of opportunity may be the size of house in high school,
but in college it shrinks to the size of a room and if you make it to the pros,
that window of opportunity is the size of a basketball.”
“it is likely the same in surgery as one is in training, the type of cases
become more complex, so your skill set must increase, and the windows of
opportunity to succeed become smaller and smaller as you tackle more difficult
procedures. Like surgery as the levels get tighter, the windows of opportunity
to succeed are smaller”. (Brilliant man)
“Before the snap the quarterback expects that his receiver will be where he is
supposed to be, so he no longer worries about where the receiver is after the
play (huddle or audible) is called. He now spends time looking for that one
person in the defense who tells him the defense is where he thinks they should
be. A great defensive coach can disguise his defense and take advantage of that
tiny window of opportunity. When a quarterback throws an interception and you
see they looked perplexed, eight times out of ten, it is because the receiver
was in the wrong location and the defense took advantage over that. The
quarterback is NOT looking for the receiver but throwing exactly where the
receiver is supposed to be. When a mistake happens it is because the receiver
is supposed to run 7 yards but ran 8 or 10 instead. It is all about the timing.
Now, where the receiver is supposed to be, there is a defender there. Other
times the defender did not do what the quarterback predicted. He miscalculated
what the defender’s intentions were. Some teams are REALLY good at this. In
some cases the quarterback can pick up that the intended receiver is not open
so they must then rely on the back side receiver to be open.”
Ok that was interesting, no doubt, but does that pertain to surgery? Well
somewhat yes. We know what surgery we plan to do and we know what we need, but
certainly if the team is not mentally in synch with us, the opportunity for a
mistake to occur happens. If we huddle briefly before the case (it takes 30
seconds) then if someone is not fully on board, we can figure that out and
avoid unnecessary distractions during the case. We ought to call audibles
during the case when the situation changes, but we become overly afraid that
the audible we call is misinterpreted, it can be taken out of context and
broadcasted erroneously around the hospital (Dr. Lipshy said he thought he
injured the ureter….!!!) which I have seen done. Having said that, when we are
sure there may be a problem, an audible needs to be called as a critical pause
so we can be sure everyone is focused and not distracted by inconsequential
things. Well I tried to tie it into surgery, but likely failed.
DEALING WITH FAILURE:
I quickly came up with a question that I had not thought of: “how does one
brush off their mistakes (their bad outcomes) and come back to work on the next
possession?” I immediately remembered a conversation regarding risk taking and
risk avoidance, I had with Dr. Moulton back in December on their paper: “Taking
a chance or playing it safe: reframing risk assessment within the surgeon’s
comfort zone.” Certainly having a bad outcome in surgery can shape our
mentality about tackling a similarly difficult case in the future- that is, we
become risk aversive.
“Risk tasking after a bad encounter—that’s an “age old question”, the great
ones, the Peyton’s and Tom Brady’s have a balance. They obviously have a
certain element of self-confidence based on their skills. The higher the skills
the more risk you are willing to take. In some quarterbacks, it is based on
self-esteem and they figure out later they don’t have the skills. That
Quarterback has no anticipation, and eventually they begin to hesitate and fail
or they have too much confidence and are being cocky and that will catch up to
them.”
“Some quarterbacks are at risk for blocking if they have too many mistakes after
taking risk and that can shut you down”.
“I taught my young sons to learn there are layers to skill sets- you must have
footwork, ‘if my feet are not in the right position, then the ball handling
won’t matter’. They learned that a good quarterback needs a lot of layers of
fundamental skills that need to be in place before you gain the mental part.
You need the basic skills of footwork, then ball handling and then the mental
parts.”
OK, well that is even more like surgery. If you learn and rely on your basic
surgical skills first, then when you gain the knowledge you should be able to
handle the stress of a setback. If all you have is the knowledge but not a bank
of skill sets, then you could be in trouble especially if your peer support
crumbles.
LEADERSHIP TRAINING IN COACHING: SKILLS FOR A LIFETIME
This then brought up my thoughts about leadership and mentorship: what type of
coaching mentality works best? You have the paternal nurturing figure of some
coaches as opposed to the stricter fearing tactics of other coaches.
Coach McCoy stated that it “has to do with recruiting to that exact level.
Surprisingly it is typically opposite how the kid was brought up. You have to
have the right kid in the right environment. The way they react to the
different styles is different. A kid in a tough strict environment may actually
do better in a paternal environment, while a kid brought up in loosely
controlled family environment may be better off in a very strict controlled
coaching style.”
In the end all coaches must be more “concerned about what happens with the
athlete after the football is over for them. You must work to mold an adult who
can function in the world no matter what they chose to become. If all you worry
about is your successes, then you may have missed the opportunity to mold the
student into a functioning member of society. You must be there to nurture them
some, or you have failed.”
“This is where the Coaches leadership training comes in. The coach must teach
the boys leadership skills they can use on the field and off. We at the Flippen
group utilized professional development raising high performance professionals.
We focus leadership- command control and structure vs relational control. This
works in all environments. A good coach or leader needs to keep a fine balance
between the two. If I have too much command control that can be overwhelming
and end up being a constraint to the people around me, then I need to work on
my perception on my team. It’s not always about where I see myself, but where others
see me.”
“After coaching for 28 years, including my boys Colt and Case, I realized the
potential to use my love of teaching leadership skills for use in other areas.
The Flippen group uses measures of BEHAVIOR TENDENCIES (self-control,
nurturing, deference level, etc ) as a profiling process and not PERSONALITIES
(Meyers Briggs)- personality profiles do not induce change but move you to a
like personality or teach you how to deal with other personalities– I looked at
what are the constraints preventing our being the best? When the going gets
tough, we tend to focus not on our weakness but focus on our reliance on our
strength too much. Well, maybe that strength was actually what led us in the
wrong direction, or maybe if I understood my weaknesses I could capitalize on
that or utilize another person who is stronger in that area for us to succeed.
We don’t focus on changing your personality, but changing your behavior.”
Ah, well this brought to mind several things…. We as surgical teachers should
focus more on providing the surgical trainees with the skill sets needed to be
leaders in whatever environment they are in. Just this week we learned that the
APDS is asking our Program directors to assume more responsibility for our
students when they have completed training….Well, that is in actuality what a
Coach should be doing with his or her athletes…. Sure racking up five national
championships brings in alumnus dollars, but teaching the players to leaders in
society, PRICELESS, and that should be a focus in our training programs. I
understand that many sites have avid leadership programs (Dukes Feagin
leadership program for one) but every resident should be able to state that not
only can they function in the hospital without supervision, but that they have
the capacity to lead at their Hospital.

(For those of you not members of the ACS General Surgery
Community-Tyler Hughes asked me to post
this. The response was, as I suspected, ALL OVER THE PLACE. I am not copying
the responses of this private community, but this was my overall message)

For those not aware, the American College of Surgeons
(ACS) and the American Academy of Orthopedic Surgeons (AAOS) hosted the
first National Surgical Patient Safety Summit (NSPSS) Program Aug
4-5 2016 in Chicago IL. The mission of the program was to "propose
solutions that effectively combine elements of safety science, principles of
high reliability and best safety practices across all phases of surgical
care." Key leaders from the ACS and AAOS have been meeting over the past
two years to establish the framework for proceeding with a safety summit. The
preliminary workgroup identified key surgical safety content (knowledge),
current knowledge gaps, and key evidence / consensus-based surgical safety
practices and behaviors. This initial group expanded to include the ASA and
AORN to draft initial safety standards, propose content for safety education
programs, and identify surgical safety data needed to improve safety for
surgical patients. (Summary located at: http://crisislead.blogspot.com/2016/08/national-surgical-patient-safety-summit_8.html
)

As expected the topic frequently turned towards our constant shift in medicine
to create aviation crew H.R.O. models to improve patient safety. The group
noted pros and cons in using that model. In typical fashion, the speakers often
related seemingly factual information about Pilot Aviation Training
requirements and as usual, I was a bit incredulous about the validity of these
statements. In this particular case several in the audience indicated that
pilots would not undergo annual testing and crew management training unless
forced to do so. I have been known to accost pilots and crews frequently in
airports and hotels to ask them to refute or validate rumors I have heard from
others (Ie post flight debriefing sessions, Sleep hazard regulations etc).

Upon leaving the NSPSS,
as luck would have it, Two United Airline pilots (one my age and a younger
pilot) accompanied me on the airport shuttle. As they were reviewing their
updated weather reports and radar screens, I interrupted them to inquire
exactly what requirements we imposed on pilots for crew and simulation
training. Since we spent the last 24 hours discussing the comparison of
aviation and patient safety I felt I needed to inquire. They stated that within
their organization all training is uniform. The FAA has specific requirements
regarding training modules but otherwise training may differ amongst airlines.
They are required to attend simulation with a co-pilot from their organization
every 9 months. Once a year they join up with the entire airline team for an
afternoon to go thru emergency procedures - the entire flight and ground crew
(no the pilots are not replace by actors because the pilots are too busy and
not incentivized to participate, but actual pilots are engaged in this
simulation exercise).

When asked their
opinion about mandated training it was clear that it was not viewed as
burdensome. When I had an incredulous look, he reminded me about the flight
that ran out of fuel when the crew was totally fixated on the landing gear
light that would not turn off. He said that it is now viewed as a
partnership between the pilots, the FAA and the airlines so they are not
reluctant to disclose and discuss near misses and mistakes as compared to the
past punitive process. They said they would definitely do the training annually
voluntarily because it is a valuable educational experience. http://crisislead.blogspot.com/2016/08/post-nspss-interview-with-airline.html

To be honest I was worried no one would be responding to this post. The fact
that some have responded means there is hope for us. The fact that we are clearly
divided in our interpretation of this facet in medical history, means we need
to collaborate more than ever. As History teaches us, if we don’t make a
responsible decision for how we manage public care, the public will decide for
us. Everything everyone said on these posts was clearly noted by surgical
leaders at the Joint ACS-AAOS NSPSS meeting earlier this month. Believe me when
I say that Dr. Hoyt is clearly concerned as well. He made it crystal clear that
the teams who made the recommendations prior to the meeting established these
recommendations as a latticework for ongoing collaboration and improvement with
the ultimate goal of producing guidelines that represented tried and true
methods of improving patient safety without compromising overall operative
safety or efficiency. But they want our input!!!! If you have constructive
advice on how to fix this contact Dr. Hoyt ASAP! He has heard all the criticism
but not many viable solutions.

Yes, we have a lot to be concerned about. Dr. Pellegrini and I discussed this
last Summer when the surgical community was divided over the Canadian study by
Baxter on lack of apparent effects of sleep deprivation on surgeons in their
study. Following that I talked with Dr. Baxter and the FAA (http://crisislead.blogspot.com/2016/03/myth-or-reality-2-fatigue-and_29.html).
I quickly discovered that while on the surface the data for sleep deprivation
in pilots seemed reasonable, the facts were not all that clear. Public outrage
after mishaps reportedly due to distracted pilots inevitably forced the FAA's
hand to make a decision. The FAA was already working on the issue, but with
public concern on the line, a decision was made sooner than they intended. I
believe we have seen this pattern before in resident education. The writing is
on the wall. If we don't develop protocols based on proven methodologies,
someone else will, then we will have no course but to comply.

The bottom line is that data indicates the trend in sentinel events is not
changing for the better. I discussed this with LD Britt last month (hope to
have our manuscript with that interview published sometime soon -maybe the ACS
Bulletin). Dr. Britt was crystal clear in noting that surgeons are missing
an opportunity here. Unlike aviation, nuclear power, etc, no single HRO model
will work in medicine. We all agree it is too complex. No single step will
work- not one standardized process- but a series of protocols will- but only
with physician buy-in. No, the pilots don’t kick the tires or check the engines
prior to take off, but surgeons don’t inspect the anesthesia machines before
surgery (and we all complain when something on the case card is not in the room
but seldom go thru the entire card to make sure everything is there prior to
takeoff). It is a community effort. It takes a team. Having said that, if we
don't want the FAA equivalent in medicine (CMS?) mandating protocols that don't
make sense, then surgeons need to design the preflight check system, team
training/communication simulation, video based coaching ( http://crisislead.blogspot.com/2016/05/innovative-strategies-for-improving_25.html),
certification processes and the like. Our opportunity is here but that is
only transient as the public will likely not be patient for long. If you
have solutions, then Call or write Dr Hoyt NOW! State boards are already
mandating sentinel event reporting. Caprice Greenberg made it clear that in the
right hands, video based coaching can improve performance, but dissent about
recording operations was clear in the NSPSS audience as laws are being
considered to force physicians to record procedures when patients ask- and then
hand the discs over! Some states are considering laws mandating surgeons
reporting to patients when they have experienced excessive hours awake prior to
operating. I am working with one state that has 130 hospitals who is
considering a statewide implementation of the WHO protocol similar to South
Carolina- the SC project was developed by – yes you better believe it- the
state Hospital Association. Mandated annual simulation and other competency training
for physicians is being considered in many states. The public does not want to
wait any longer. The public wants-get ready for this- ZERO ERROR.
Imagine what that will do for attempting to implement a safety culture if
every single error we make is documented at the state or national
level. How much more difficult will honest disclosure and performance
improvement become if state legislatures report and track online every
mistake made in medicine? If we want transparency, then we need to take
control. We need to come to common ground and agree on goals, methods,
validation, certification, whatever.

So unless we simple want to throw up our hands and accept what others mandate
for us, the time to design this process is here and now, but rapidly dissipating
as hospital administrators and other professionals -as well as the public
- are growing impatient. They simply will not sit on their hands for long.
Surgeons Stand up and figure out what will work that will provide safe care and
not impede the flow of surgery. Lord knows we already do not have enough
surgeons to go around and cannot afford to slow things down and reduce our
productivity or we will then experience delays in care.

So
let’s team up and figure out what will improve patient safety, garner team
spirit, and not reduce efficiency. There simply has to be a better way.

Sunday, August 21, 2016

On July 21st 2016 a tweet went out with the subject line:
“Disclosure of harm is a must-Would a surgeon tell you if something went
wrong?” followed by the commentary “new survey of surgeons reveals the truth
about disclosure and medical errors”. My immediate assumption was that this must
be a bad news release revealing that surgeons do not inform their patients when
mistakes or complications happen (and assume d that the public likely had the
same perception).To my relief the CBS
website - Disclosure of
harm is a must - Would a surgeon tell you if something went wrong?Disclosure of
harm is a must - Would a surgeon tell you if something went wrong?July 20th news feed “would
a surgeon tell you if something went wrong during your operation?” reported
that the study revealed that most Veterans
Health Administration (VHA) surgeons do follow guidelines for disclosure when a procedure has an
associated adverse event. On that note I
retrieved the VHA study, contacted the authors (Elwy, Itani and Perkal) to
discuss this further and reviewed the VHA policies on disclosure of adverse
events.I learned that the process for
making recommendations and the institution of policy within VHA and elsewhere
on the disclosure of adverse events has been relatively slow, but while there
is clearly a ways to go in this endeavor, progress is being made.

While a local policy on
disclosure of adverse events was published at the Lexington VAMC in 1987, it
was not until 1995 that VHA published a National VHA policy requiring
disclosure to patients. The process was relatively unknown
to most until the National VHA Ethics Committee published a Disclosure of
Adverse Events report in 2003. This report recommended the disclosure of
adverse events to the patients and/or their families when the following
criteria existed:

·The
adverse event has a perceptible effect on the patient that was not discussed in
advance as a known risk.

·The
adverse event necessitates a change in the patient’s care.

·The
adverse event potentially poses a significant risk to the patient’s future
health, even if the likelihood of that risk is extremely small.

·The
adverse event involves providing a treatment or procedure without the patient’s
consent.

In this
report the definition of Adverse Events was “untoward incidents, therapeutic
misadventures, iatrogenic injuries, or other adverse occurrences directly
associated with care or services provided within the jurisdiction of a medical
center, outpatient clinic, or other VHA facility. Adverse Events may result
from acts of commission or omission (e.g., administration of the wrong
medication, failure to make a timely diagnosis or institute the appropriate
therapeutic intervention, adverse reactions or negative outcomes of treatment).
Some examples of more common Adverse Events include: patient falls, adverse
drug events, procedural errors and/or complications, completed suicides,
parasuicidal behaviors (attempts, gestures, and/or threats), and missing
patient events.”

Even
in 2003, disclosure policies were viewed as extreme and followed less than
whole-heartedly. Physicians were very skeptical about disclosure policies
leading many compelled to disclose incomplete or inaccurate information. This
reluctance was centered on legitimate and unfounded concerns about legal and
financial ramifications. In addition, physicians were concerned about the
negative consequences of the emotional stress on the family or patient by
revealing that information (‘too much information can be harmful on the
spirit’).

Subsequent
to that 2003 report several VHA Handbooks on disclosure of adverse events to
patients were published- the most recent of which is VHA HANDBOOK 1004.08
October 2012. In this document Adverse
Events were defined as “untoward incidents, diagnostic or
therapeutic misadventures, iatrogenic injuries, or other occurrences of harm or
potential harm directly associated with care or services provided within the
jurisdiction of the Veterans Healthcare System.”

VHA
HANDBOOK 1004.08 stipulates that
institutional disclosure must be initiated “as
soon as reasonably possible and generally within 72 hours. This timeframe does
not apply to adverse events that are only recognized after the associated
episode of care (e.g., through investigation of a sentinel event, a routine
quality review, or a look-back). Under such circumstances, if the adverse event
has resulted in or is reasonably expected to result in death or serious injury,
institutional disclosure is required, but disclosure may be delayed to allow
for a thorough investigation of the facts provided.”

According to the
2012 Handbook, Institutional disclosure of adverse events must document the
following SEVEN steps in the medical director:

(1) An expression
of concern and an apology, including an explanation of the facts to the extent
that they are known.

(2) An outline of
treatment options, if appropriate.

(3) Arrangements
for a second opinion, additional monitoring, expediting clinical consultations,
bereavement support, or whatever might be appropriate depending on the
circumstances and within the constraints of VA’s statutory and regulatory
authority.

(4) Contact
information regarding designated staff who are to respond to questions

(5) Notification
that the patient or personal representative has the option of obtaining outside
medical or legal advice for further guidance.

(6) Offering
information about potential compensation under 38 U.S.C. § 1151 and the Federal
Tort Claims Act where the patient is a Veteran or under the Federal Tort Claims
Act where the patient is a non-Veteran.

(7) Ongoing
communication whereby the Risk Manager or organizational leaders engage the
patient or personal representative to keep them apprised, as appropriate, of
information that emerges from investigation of the facts related to the adverse
event.

Literature discussion, regarding the physician
experience relating to disclosure of adverse events to patients, spans the
spectrum from positive (provision of an outlet for the emotional toll) to
negative (concerns of repercussions, shame guilt) emotions. Few studies have
assessed the emotional experience of physicians after exposure to disclosure of
an adverse event by survey. By gaining this knowledge educating physicians on
disclosing adverse events may become more effective thereby improving the
outcome of the disclosure process with patients and physicians.Elwy et al set out to assess

A.The compliance with each of the eight elements
recommended by the National Quality Forum and The VA (see inset RATE OF
COMPLETION OF EIGHT RECOMMENDED DISCLOSURE STEPS ACCORDING TO INTERVIEWED
PHYSICIANS below) as well as the relative likelihood of disclosure based on the
risk of harm due to the adverse event (literature supports that surgeons are
more likely to disclose if the event has a risk for high harm than with low
harm).

B.
the emotional experience of physicians who provided such disclosure to
determine if those physicians that followed the disclosure policy were more or
less likely to experience negative effects as suspected above.

C.
The relationship of physician attitude regarding disclosure with the effect on
that physician following disclosure.

Before
discussing this with the lead author, Dr. Elwy, I researched the question: What makes it so difficult to disclose
adverse events to patients? The obvious reason for anxiety in this
process is the fear of repercussions. The not so obvious reason is our response
and recognition of failure. Amy Edmondson reminds us in her book (p. 155) that
success in business comes with a risk of failure and that it is important to
accept failure as an outcome. This may be much more difficult in practice than
in principle however. Humans have a natural aversion to failure itself causing
public discussion of their failure extremely difficult. It is our fundamental
nature to preserve our self-esteem. Compounding that is our innate heuristic
trait of confirmation bias which prevents our dismissing any early conception
of an event and instead leads to distortion of the facts to support our
conclusion that this was "not my fault". We find it easier to
diminish our responsibility and blame others to preserve our dignity in front
of our peers. This then strengthens the emotion surrounding any discussion of
failure. For us to analyze and discuss failure we must be open, patient and
tolerate ambiguity. For this to occur we must be taught humility in our
training. To be fair, when we fail, we theoretically risk punishment in medicine
either by our peers at the medical executive board, hospital leadership, state
licensing boards or ultimately in the courts. Furthermore, the public is quick
to equate failure with liability. Frankly it is difficult to blame them for
that preconceived notion given the volume of commercialism focused on class
action litigation and the like in the media.

On
that note, Dr. Elwy was very gracious to talk with me about this paper and her
processes of implementing this study:

Dr.
Elwy, I agree we need to rethink how we disclose adverse events in medicine but
it is a very emotional process that appears to instill anxiety in most of us
for one reason or another as I alluded to in my discussion of this paper. What prompted this study? What prompted
your group to look at this?

·Dr.
Elwy- let me start with a disclaimer that
I am not a surgeon, I am a psychologist.I have always had an interest in the disclosure process. In my PhD
dissertation I began with a discussion about how physicians disclose bad
information to parents who have deliveries of babies with challenging medical
conditions. I had an emotional experience personally regarding a child in which
a surgeon presented to me an eloquent discussion about an adverse event. I
became interested in how patients feel and what surgeons feel during this
process. When I moved here I wanted to begin a study assessing this further. I
approached Dr. Itani in 2007 and he was very engaging. He suggested we start
with a pilot study because everyone doubted surgeons would be willing to participate.
There was skepticism that the IRB would approve a study where we discussed this
with surgeons. Everyone was concerned about surgeons as a vulnerable population
and about confidentiality, and coercion - enrollment issues. We were relieved
that the pilot confirmed these concerns were unfounded. What we found was that Surgeons
in this small group were not aware of VHA guidelines but did disclose what they
said to patients.

What were some of your take home messages
from this study?

Dr.
Elwy-

1.Surgeons who were more likely to be negatively affected by
the event were less likely to discuss prevention, as they felt that that the
event was serious and found it very difficult to discuss the event.

2.Surgeons noted that they frequently told the family more
than was required. Many noted they did apologize but it was clear that perhaps
the definition of what is an apology is not well defined.We learned that patients want to hear an
expression of concern. They want the surgeons to be honest and transparent.
They want to know the surgeon is concerned about what happened to them. It
turns out that simply saying ‘I am sorry you have to go thru this’ is
sufficient in most cases. They do not want a very formal apology. They don’t
even expect that I take the responsibility for the incident, just that I am
empathetic. It is not clear that the surgeons understood what an apology really
was because the patients frequently said they were given an apology and several
surgeons stated they did not offer a formal apology. All the patients conveyed
that they were satisfied when the surgeon was concerned about them and their
condition and that the surgeon was as concerned about the patient as the
patient was. Surgeons often equated an apology to a formal acceptance of
responsibility for the patient’s condition and that actually was not what the
patients were looking for.

3.Many noted that the negative connotation of this process
arises from the fact that Risk Management typically institutes or manages this
process instead of Quality management. One of the biggest suggestions was that
this process was best managed by quality and probably not risk management. If
the connotation is risk management, this creates a significant barrier in these
frank conversations. We need to move away from the perception that these
conversations are a bad thing. “it matters more what the patient hears and it
is apparent they want to hear the surgeon is concerned and want the patient to
be better.”

What do we need to do to break down the
barrier to surgeons feeling comfortable in this process especially given the
inherent nature of these events and surgeon personalities in general (as noted
above)?

Dr.
Elwy: There is a lot of anxiety about
disclosure. There is a lot of fear. There are many misperceptions. We need to
teach that this is positive. We need to teach that the surgeon just needs to be
open and honest. Even in the Surgeons who agreed to do the study, had some
negative attitudes so we can infer that those who did not volunteer possibly
had a more significant negative attitude. Those that had a negative attitude,
had more anxiety about disclosure.

Were you able to assess surgeon exposure
personally to negative responses they may have experienced during this process
following a negative patient outcome such as bad publicity, bad exposure in the
hospital peer review process, legal action, to see if that may explain the
reaction? I discussed risk aversion and risk taking previously with Dr. Moulton
after they wrote about why we are risk averse or bold when we take on surgical
cases (http://crisislead.blogspot.com/2016/08/comfort-zones-and-risk-taking-in.html)

Dr.
Elwy: Because the survey was short and we
wanted to encourage participation this was not specifically asked but there was
a block to discuss this. The interviews were about a very specific case and the
study designed prevented more expansive disclosure. The surgeons were asked to
account how they managed specific cases. Family members were then contacted and
interviewed- thru patient safety. Plus we had to keep the surgeon interviews to
less than 20-25 minutes to respect their time.

Any
final message about this you wanted to convey?

Dr.
Elwy: Unfortunately there is no avenue
for surgeons to discuss this. M&M is not the place. This sets the surgeons
up for burnout. We need this process to build up resilience. Would recommend we
think about what others have said on this topic.

Marjorie Siegler wrote a piece about
this in JAMA, where she notes that after a catastrophic event all other
professionals have period of time to regroup prior to going back on duty. Further
studies need to be done to assess what support is needed after a traumatic
event. Physicians do not want to discuss this with a mental health provider.
Physicians want to talk to a peer who has had that same experience. Jo Shapiro’s,
Brigham Women’s, Center for Professionalism and Peer Support designed for that
purpose. http://www.brighamandwomens.org/medical_professionals/career/cpps/default.aspx

On July 21st 2016 a tweet went out with the subject line:
“Disclosure of harm is a must-Would a surgeon tell you if something went
wrong?” followed by the commentary “new survey of surgeons reveals the truth
about disclosure and medical errors”. My immediate assumption was that this must
be a bad news release revealing that surgeons do not inform their patients when
mistakes or complications happen (and assume d that the public likely had the
same perception).To my relief the CBS
website - Disclosure of
harm is a must - Would a surgeon tell you if something went wrong?Disclosure of
harm is a must - Would a surgeon tell you if something went wrong?July 20th news feed “would
a surgeon tell you if something went wrong during your operation?” reported
that the study revealed that most Veterans
Health Administration (VHA) surgeons do follow guidelines for disclosure when a procedure has an
associated adverse event. On that note I
retrieved the VHA study, contacted the authors (Elwy, Itani and Perkal) to
discuss this further and reviewed the VHA policies on disclosure of adverse
events.I learned that the process for
making recommendations and the institution of policy within VHA and elsewhere
on the disclosure of adverse events has been relatively slow, but while there
is clearly a ways to go in this endeavor, progress is being made.

While a local policy on
disclosure of adverse events was published at the Lexington VAMC in 1987, it
was not until 1995 that VHA published a National VHA policy requiring
disclosure to patients. The process was relatively unknown
to most until the National VHA Ethics Committee published a Disclosure of
Adverse Events report in 2003. This report recommended the disclosure of
adverse events to the patients and/or their families when the following
criteria existed:

·The
adverse event has a perceptible effect on the patient that was not discussed in
advance as a known risk.

·The
adverse event necessitates a change in the patient’s care.

·The
adverse event potentially poses a significant risk to the patient’s future
health, even if the likelihood of that risk is extremely small.

·The
adverse event involves providing a treatment or procedure without the patient’s
consent.

In this
report the definition of Adverse Events was “untoward incidents, therapeutic
misadventures, iatrogenic injuries, or other adverse occurrences directly
associated with care or services provided within the jurisdiction of a medical
center, outpatient clinic, or other VHA facility. Adverse Events may result
from acts of commission or omission (e.g., administration of the wrong
medication, failure to make a timely diagnosis or institute the appropriate
therapeutic intervention, adverse reactions or negative outcomes of treatment).
Some examples of more common Adverse Events include: patient falls, adverse
drug events, procedural errors and/or complications, completed suicides,
parasuicidal behaviors (attempts, gestures, and/or threats), and missing
patient events.”

Even
in 2003, disclosure policies were viewed as extreme and followed less than
whole-heartedly. Physicians were very skeptical about disclosure policies
leading many compelled to disclose incomplete or inaccurate information. This
reluctance was centered on legitimate and unfounded concerns about legal and
financial ramifications. In addition, physicians were concerned about the
negative consequences of the emotional stress on the family or patient by
revealing that information (‘too much information can be harmful on the
spirit’).

Subsequent
to that 2003 report several VHA Handbooks on disclosure of adverse events to
patients were published- the most recent of which is VHA HANDBOOK 1004.08
October 2012. In this document Adverse
Events were defined as “untoward incidents, diagnostic or
therapeutic misadventures, iatrogenic injuries, or other occurrences of harm or
potential harm directly associated with care or services provided within the
jurisdiction of the Veterans Healthcare System.”

VHA
HANDBOOK 1004.08 stipulates that
institutional disclosure must be initiated “as
soon as reasonably possible and generally within 72 hours. This timeframe does
not apply to adverse events that are only recognized after the associated
episode of care (e.g., through investigation of a sentinel event, a routine
quality review, or a look-back). Under such circumstances, if the adverse event
has resulted in or is reasonably expected to result in death or serious injury,
institutional disclosure is required, but disclosure may be delayed to allow
for a thorough investigation of the facts provided.”

According to the
2012 Handbook, Institutional disclosure of adverse events must document the
following SEVEN steps in the medical director:

(1) An expression
of concern and an apology, including an explanation of the facts to the extent
that they are known.

(2) An outline of
treatment options, if appropriate.

(3) Arrangements
for a second opinion, additional monitoring, expediting clinical consultations,
bereavement support, or whatever might be appropriate depending on the
circumstances and within the constraints of VA’s statutory and regulatory
authority.

(4) Contact
information regarding designated staff who are to respond to questions

(5) Notification
that the patient or personal representative has the option of obtaining outside
medical or legal advice for further guidance.

(6) Offering
information about potential compensation under 38 U.S.C. § 1151 and the Federal
Tort Claims Act where the patient is a Veteran or under the Federal Tort Claims
Act where the patient is a non-Veteran.

(7) Ongoing
communication whereby the Risk Manager or organizational leaders engage the
patient or personal representative to keep them apprised, as appropriate, of
information that emerges from investigation of the facts related to the adverse
event.

Literature discussion, regarding the physician
experience relating to disclosure of adverse events to patients, spans the
spectrum from positive (provision of an outlet for the emotional toll) to
negative (concerns of repercussions, shame guilt) emotions. Few studies have
assessed the emotional experience of physicians after exposure to disclosure of
an adverse event by survey. By gaining this knowledge educating physicians on
disclosing adverse events may become more effective thereby improving the
outcome of the disclosure process with patients and physicians.Elwy et al set out to assess

A.The compliance with each of the eight elements
recommended by the National Quality Forum and The VA (see inset RATE OF
COMPLETION OF EIGHT RECOMMENDED DISCLOSURE STEPS ACCORDING TO INTERVIEWED
PHYSICIANS below) as well as the relative likelihood of disclosure based on the
risk of harm due to the adverse event (literature supports that surgeons are
more likely to disclose if the event has a risk for high harm than with low
harm).

B.
the emotional experience of physicians who provided such disclosure to
determine if those physicians that followed the disclosure policy were more or
less likely to experience negative effects as suspected above.

C.
The relationship of physician attitude regarding disclosure with the effect on
that physician following disclosure.

Before
discussing this with the lead author, Dr. Elwy, I researched the question: What makes it so difficult to disclose
adverse events to patients? The obvious reason for anxiety in this
process is the fear of repercussions. The not so obvious reason is our response
and recognition of failure. Amy Edmondson reminds us in her book (p. 155) that
success in business comes with a risk of failure and that it is important to
accept failure as an outcome. This may be much more difficult in practice than
in principle however. Humans have a natural aversion to failure itself causing
public discussion of their failure extremely difficult. It is our fundamental
nature to preserve our self-esteem. Compounding that is our innate heuristic
trait of confirmation bias which prevents our dismissing any early conception
of an event and instead leads to distortion of the facts to support our
conclusion that this was "not my fault". We find it easier to
diminish our responsibility and blame others to preserve our dignity in front
of our peers. This then strengthens the emotion surrounding any discussion of
failure. For us to analyze and discuss failure we must be open, patient and
tolerate ambiguity. For this to occur we must be taught humility in our
training. To be fair, when we fail, we theoretically risk punishment in medicine
either by our peers at the medical executive board, hospital leadership, state
licensing boards or ultimately in the courts. Furthermore, the public is quick
to equate failure with liability. Frankly it is difficult to blame them for
that preconceived notion given the volume of commercialism focused on class
action litigation and the like in the media.

On
that note, Dr. Elwy was very gracious to talk with me about this paper and her
processes of implementing this study:

Dr.
Elwy, I agree we need to rethink how we disclose adverse events in medicine but
it is a very emotional process that appears to instill anxiety in most of us
for one reason or another as I alluded to in my discussion of this paper. What prompted this study? What prompted
your group to look at this?

·Dr.
Elwy- let me start with a disclaimer that
I am not a surgeon, I am a psychologist.I have always had an interest in the disclosure process. In my PhD
dissertation I began with a discussion about how physicians disclose bad
information to parents who have deliveries of babies with challenging medical
conditions. I had an emotional experience personally regarding a child in which
a surgeon presented to me an eloquent discussion about an adverse event. I
became interested in how patients feel and what surgeons feel during this
process. When I moved here I wanted to begin a study assessing this further. I
approached Dr. Itani in 2007 and he was very engaging. He suggested we start
with a pilot study because everyone doubted surgeons would be willing to participate.
There was skepticism that the IRB would approve a study where we discussed this
with surgeons. Everyone was concerned about surgeons as a vulnerable population
and about confidentiality, and coercion - enrollment issues. We were relieved
that the pilot confirmed these concerns were unfounded. What we found was that Surgeons
in this small group were not aware of VHA guidelines but did disclose what they
said to patients.

What were some of your take home messages
from this study?

Dr.
Elwy-

1.Surgeons who were more likely to be negatively affected by
the event were less likely to discuss prevention, as they felt that that the
event was serious and found it very difficult to discuss the event.

2.Surgeons noted that they frequently told the family more
than was required. Many noted they did apologize but it was clear that perhaps
the definition of what is an apology is not well defined.We learned that patients want to hear an
expression of concern. They want the surgeons to be honest and transparent.
They want to know the surgeon is concerned about what happened to them. It
turns out that simply saying ‘I am sorry you have to go thru this’ is
sufficient in most cases. They do not want a very formal apology. They don’t
even expect that I take the responsibility for the incident, just that I am
empathetic. It is not clear that the surgeons understood what an apology really
was because the patients frequently said they were given an apology and several
surgeons stated they did not offer a formal apology. All the patients conveyed
that they were satisfied when the surgeon was concerned about them and their
condition and that the surgeon was as concerned about the patient as the
patient was. Surgeons often equated an apology to a formal acceptance of
responsibility for the patient’s condition and that actually was not what the
patients were looking for.

3.Many noted that the negative connotation of this process
arises from the fact that Risk Management typically institutes or manages this
process instead of Quality management. One of the biggest suggestions was that
this process was best managed by quality and probably not risk management. If
the connotation is risk management, this creates a significant barrier in these
frank conversations. We need to move away from the perception that these
conversations are a bad thing. “it matters more what the patient hears and it
is apparent they want to hear the surgeon is concerned and want the patient to
be better.”

What do we need to do to break down the
barrier to surgeons feeling comfortable in this process especially given the
inherent nature of these events and surgeon personalities in general (as noted
above)?

Dr.
Elwy: There is a lot of anxiety about
disclosure. There is a lot of fear. There are many misperceptions. We need to
teach that this is positive. We need to teach that the surgeon just needs to be
open and honest. Even in the Surgeons who agreed to do the study, had some
negative attitudes so we can infer that those who did not volunteer possibly
had a more significant negative attitude. Those that had a negative attitude,
had more anxiety about disclosure.

Were you able to assess surgeon exposure
personally to negative responses they may have experienced during this process
following a negative patient outcome such as bad publicity, bad exposure in the
hospital peer review process, legal action, to see if that may explain the
reaction? I discussed risk aversion and risk taking previously with Dr. Moulton
after they wrote about why we are risk averse or bold when we take on surgical
cases (http://crisislead.blogspot.com/2016/08/comfort-zones-and-risk-taking-in.html)

Dr.
Elwy: Because the survey was short and we
wanted to encourage participation this was not specifically asked but there was
a block to discuss this. The interviews were about a very specific case and the
study designed prevented more expansive disclosure. The surgeons were asked to
account how they managed specific cases. Family members were then contacted and
interviewed- thru patient safety. Plus we had to keep the surgeon interviews to
less than 20-25 minutes to respect their time.

Any
final message about this you wanted to convey?

Dr.
Elwy: Unfortunately there is no avenue
for surgeons to discuss this. M&M is not the place. This sets the surgeons
up for burnout. We need this process to build up resilience. Would recommend we
think about what others have said on this topic.

Marjorie Siegler wrote a piece about
this in JAMA, where she notes that after a catastrophic event all other
professionals have period of time to regroup prior to going back on duty. Further
studies need to be done to assess what support is needed after a traumatic
event. Physicians do not want to discuss this with a mental health provider.
Physicians want to talk to a peer who has had that same experience. Jo Shapiro’s,
Brigham Women’s, Center for Professionalism and Peer Support designed for that
purpose. http://www.brighamandwomens.org/medical_professionals/career/cpps/default.aspx